Patient Complaints

If you experience a situation in which a pharmacist, in your opinion, has behaved unethically, please complete and submit this form. The complaint will then be processed by the Ethics & Practice Commission of the Michigan Pharmacists Association, the association's judicial division. The Ethics & Practice Commission meets approximately three times a year.

Michigan Pharmacists Association is the state professional society of pharmacists. Pharmacist members of the Association subscribe to a Code of Ethics, including peer review of professional practices and standards.

The personal and professional rights of all parties are recognized as the Commission administers the complaint according to established policies and procedures. The time required for the hearing and review process will vary, depending on the nature and scope of the complaint. If the case requires further fact-finding, you will receive progress reports. A final report of the disposition of the case will be forwarded to you.

Please complete this complaint with as much information and detail as possible. Be sure to print out a copy for your files. If you have additional questions, please contact MPA Executive Assistant Melody Arnst by calling (517) 377-0252.

 

Complaint filed against:
Pharmacy name:
Phone:
Address:
City:
State:
Zip Code:
Pharmacist's Name:
If pharmacist's name is unknown to you, do not hesitate asking him or her for that information. Otherwise, note the pharmacist's initials on the prescription label and compare it to the licensure certificate required to be displayed in the pharmacy.

Filed by
Your Name:
Address:
City:
State:
Zip Code:
County:
Daytime Phone:
E-mail Address:

Has this complaint been brought before other agencies or public officials?
Yes No
If yes, please specify:

Statement of Complaint:
I understand that in submitting this complaint, I authorize the release of prescription record information and copy of this document against whom the complaint is filed, should it be necessary in processing this complaint.

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